Utilization Management RN - Remote

Performs chart review of identified patients to identify quality, timeliness and appropriateness of patient care Conducts admission reviews for Medicare, Medicaid beneficiaries, as well as private insurers and self-pay patients, based on appropriate guidelines Uses these criteria guidelines to screen for appropriateness for inpatient level of care or observation services based on physician certification Gathers clinical information to conduct continued stay utilization review activities with payers on a daily basis Performs concurrent and retrospective clinical reviews with various payers, utilizing the appropriate guidelines as demonstrated by compliance with all applicable regulations, policies and timelines Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals to the physician advisor and the UR Committee Identifies, develops and implements strategies to reduce length of stay and resource consumption.